Attachment III - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C25023Q0260
View the file
Other files
| File | Type | Posted |
|---|---|---|
| RFI Responses 36C25023Q0260.pdf | ||
| Plan of Affected Floors.pdf | ||
| SOW Revised 3.9.23.docx | DOCX document | |
| 36C25023Q0260 0002.docx | DOCX document | |
| 36C25023Q0260 0001.docx | DOCX document | |
| Pre Bid Site Visit Log 1.pdf | ||
| Attachment V - VHA Directive 1192-01.pdf | ||
| Attachment I - DBA WD.txt | TXT text file | |
| Attachment IV - Limitations on Subcontracting Certificate of Compliance.pdf | ||
| 36C25023Q0260_1.docx | DOCX document | |
| Attachment II - RFI Template.doc | DOC document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25023Q0260.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| CATEGORY |
| 2019 |
| 2020 |
| 2021 |
Number of man-hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man-hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach an explanation for any violations.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
| 2. | Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220 |
| 3. | Who administers your company’s Safety and Health Program? ____________________________ |
| 4. | Company’s Insurance Experience Modification Rate (EMR): ____________________________ |
File details come from the government source that posted it. Updated .